EP3515479A1

EP3515479A1 - Treatment and/or prevention of sepsis

Info

Publication number: EP3515479A1
Application number: EP17777323.1A
Authority: EP
Inventors: Helen Connaris; Garry Taylor; Hasan YESILKAYA; Peter Andrew
Original assignee: University of St Andrews
Current assignee: Pneumagen Ltd
Priority date: 2016-09-20
Filing date: 2017-09-20
Publication date: 2019-07-31
Also published as: GB201616009D0; US20190231853A1; WO2018055365A1; US10953078B2

Abstract

The disclosure provides molecules with an affinity for (or an ability to bind to), sialic acid, for use in compositions, medicaments and methods for the treatment of sepsis, its symptoms and sepsis associated pathologies and immune responses.

Description

TREATMENT AND/OR PREVENTION OF SEPSIS

FIELD OF THE INVENTION

The invention provides molecules for use in compositions, medicaments and methods for the treatment of sepsis, its symptoms and sepsis associated pathologies and immune responses,

BACKGROUND OF THE IN VETS ON

Sepsis is a life-threatening condition that is most commonly caused by bacteria in the bloodstream, a condition known as bacteraemia. Pathogenic bacteria originating from a primary infection location, such as the lungs or urinary tract, release toxins that can provoke a dysregulafion of the innate immune response, leading to host tissue and organ damage¹.

Bacterial sepsis is a worldwide problem, generally resulting from nosocomial po!ybacterial infections, and is responsible for 25% intensive care admissions with a survival rate of around 50%².

While conventional antibiotics may be effective in killing pathogenic microorganisms in sepsis patients, they can also accelerate the release of pro-inflammatory components causing severe sepsis and shock. Alternative compounds of interest for sepsis therapy include natural occurring antimicrobial peptides (AMPs), which target pathogenic bacteria and fungi by displaying different defence mechanisms such as membrane disruption, with some having immunomodulatory activities⁴. AMPs mainly function by disabling/killing pathogen without releasing pro-inflammatory agents, However, there are several challenges with the use of AMPs as therapeutics due to their iimited pharmaceutical application such as high toxicity In most tissues, as well as the likelihood of microbial resistance⁵. Attempts to design synthetic based AMPs to reduce toxicity and stability issues are in development^®.

Multivalent Family 40 CBMs (mCBM40s) target and bind to host ceil surface sialic acid receptors with high affinity^7,8. These engineered mCBM40s also display immunomodulatory activities when given intranasal/ either alone, or in respiratory pathogen-challenged mouse models^8,9.

Despite the use of antibiotics as a control strategy for bacterial sepsis, the rise in antibiotic resistance by bloodstream bacterial isolates in recent years has highlighted an urgent need for novel compounds, therapies and regimes for the treatment and management of sepsis, its symptoms and pathologies³.

SUMMARY OF THE INVENTION

The present disclosure is based on the finding that molecules with affinity for (or an ability to bind to) sialic acid and in particular sialylated ceil surfaces (these including cell surface sialic acid receptors), find utility in the treatment and/or prevention of sepsis.

As such, the present disclosure provides a sialic acid binding molecule for use in the treatment and/or prevention of sepsis and/or one or more symptoms thereof. Further provided is the use of a sialic acid binding molecule in the manufacture of a medicament for use in the treatment and/or prevention of sepsis and/or one or more symptoms thereof.

It should be understood that throughout this specification, the terms "comprise", "comprising" and/or "comprises" is/are used to denote aspects and embodiments of this invention that "comprise" a particular feature or features, it should be understood that this/these terms may also encompass aspects and/or embodiments which "consist essentially of or "consist of the relevant feature or features.

The disclosure also relates to a method of treating or preventing sepsis and/or one or more symptoms thereof, said method comprising the steps of administering to a subject in need thereof, a therapeutically effective amount of a sialic acid binding molecule.

The term "sepsis" is applied to a number of diseases, conditions and/or syndromes which may have an infectious (for example viral, bacterial and/or fungal) aetiology. For example, term "sepsis", may embrace those disease states, conditions or syndromes referred to as SIRS (systemic inflammatory response syndrome: indicated by the presence of two or more of abnormal body temperature, heart rate, respiratory rate or blood gas and white blood cell count), sepsis {which is often defined as "SIRS in response to an infectious process"), severe sepsis (that is sepsis with sepsis-induced organ dysfunction or tissue hypoperfusion (which itself might manifest as hypotension, elevated lactate or decreased urine output) and septic shock (severe sepsis plus persistently low blood pressure despite, for example, the administration of intravenous fluids).

The term "sepsis" is most often applied to diseases, conditions and/or syndromes which result from "bacterial sepsis". Bacterial sepsis may stem from the presence of bacteria in blood and may sometimes be referred to as "bacteraemia" or "septicaemia". The term "sepsis" may also embrace diseases and/or conditions which are caused or contributed to by the presence of bacterial components such as LPS, toxins and/or membrane fragments in the blood. Components of this type may originate from primary infections present in other tissues and/or organs, for example, infections present in the lungs, brain, skin, urinary tract, pelvis and/or abdomen.

Sepsis can be a very severe condition which occasionally leads to multiple organ failure and death. There may be a number of pathologies and/or symptoms associated with each type of sepsis and these will be collectively referred to hereinafter as "sepsis associated pathologies". For example, sepsis associated pathologies may include, for example, fever, increased heart rate, increased rate of respiration and/or low blood pressure. The primary mechanism which underpins the pathology of sepsis and many of the symptoms and outcomes associated therewith is an exacerbated, exaggerated and/or inappropriate host immune response. This exacerbated immune response (which is the body's response to infection) !eads to host tissue damage and/or organ damage/failure.

The exacerbated or inappropriate immune response may include the dysregufation of innate immune responses as well as the production and/or over production of certain pro- coagulation cytokines (including, for example, tumour necrosis factor, inter!eukin 1 and interieuktn 6).

The term "subject" or "subject in need thereof as used herein, may embrace any subject who has or is at risk of developing "sepsis". For example, the subject may be one Who is predisposed or susceptible to sepsis. The "subject" may be one who has been diagnosed as suffering from one or more of the "sepsis" type pathologies described herein. The "subject" may be one who has an infection and who may go on to develop sepsis.

It should be understood that the various "sepsis" associated pathologies described above include conditions, syndromes and/or effects that may otherwise be described as "symptoms" of sepsis. As such, one or more of the sialic acid binding molecules described herein may be for use in the treatment and/or prevention of any (one or more) of these symptoms. For example, this disclosure provides any one or more of the sialic acid binding molecules described herein, for use in the treatment and/or prevention of sepsis associated: fever; immune response(s); low blood pressure; increased heart rate and/or increased rate of respiration.

Further, any of the sialic acid binding molecules described herein may be used in the manufacture of medicaments and methods for treating or preventing the same,

Without wishing to be bound by theory, it is suggested that the sialic acid binding molecules described herein are effective to dampen, suppress or inhibit the pro-inflammatory cytokine cascade that is a pre-cursor to sepsis or one or more of the symptom (s) thereof. Nevertheless, it is also suggested that the sialic acid binding molecules described herein (including the CBM-type molecules) can be used to prevent the invasive disease and/or infection(s) that can lead to sepsis. Further the sialic acid binding molecules may help reduce the pathogen burden within a subject (and thus reduce the risk of sepsis) by reducing overall pathogen carriage and/or colonisation. Again, without wishing to be bound by theory, these effects may be associated with, or linked to, the sialic acid binding nature of the molecules described herein; by binding to sialic acid, the sialic acid binding molecule (for example the CBM) prevents a pathogen from exploiting (i.e. binding to or interacting with) the presence of sialic acid in certain host receptors.

As stated, the sialic acid binding molecules which are to be used in the treatment and/or prevention of sepsis or a symptom (or pathology) thereof, exhibit an ability to bind to sialic acid of the type that is commonly found on or in cell membranes and/or cell surface receptors. Useful sialic acid binding molecules may take any form and/or belong to any class of molecuie or compound (for example they may be proteins, peptides, carbohydrates, antibodies and the like) and term "sialic acid" embraces all forms of /V- or ©-substituted neuraminic acid and includes ail synthetic, naturally occurring and/or modified forms thereof. Sialic acids may be found as components of cell surface molecules, glycoproteins and glycolipids. Most often, sialic acids are present at the end (terminal regions) of sugar chains connected to cell membranes and/or proteins. For example, some ceils of the human upper respiratory tract comprise α-2,6-linked sialic acid receptors and other cells of the upper and lower respiratory tracts comprise a-2,3-linked sialic acid receptors. The sialic acid family encompasses a number (approximately 50) of derivatives that may result from acetylation, giyco!yiation, iactonisation and methyfation at G4, C5, C7, C8 and C9. All such derivatives are to be embraced by the term "sialic acid".

Furthermore, sialic acids are found linked α(2,3) or α(2,6) to Gal and GalNAc or a(2,8) or a(2,9) to another sialic acid, Accordingly, it is important to understand that while the term "sialic acid" is used throughout this specification, it encompasses all derivatives, analogues or variants (either naturally occurring or synthetically generated) thereof as well as monomers, dimers, trimers, oligomers, polymers or concatamers comprising the same.

Thus, a sialic acid binding molecule of this disclosure (and for use as described herein) comprises a moiety which exhibits an affinity for sialic acid - including all forms of sialic acid described above and any form of sialic acid present on the surface of a cell (perhaps as part of a cell surface receptor), for example a mammalian cell. These various forms of sialic acid may be collectively referred to as "sialic acid moieties".

The sialic acid binding molecules of this disclosure exhibit an affinity for sialic acid and as such they may bind/couple to and/or associate with one or more sialic acid moieties. Thus, the term "sialic acid binding molecule" may further encompass any fragment of a whole sialic acid binding molecuie which retains an ability to bind to or otherwise couple or associate with a sialic acid moiety.

Sialic acid binding molecules for use may comprise a single sialic acid binding molecule (a monomeric or monovalent molecule, for example) or, alternatively, two or more sialic acid binding molecules - which two or more molecules may be the same or different - a polymeric or multivalent molecuie, for example.

A sialic acid binding molecule for use may comprise, consist essentially of or consist of, one or more of the sialic acid binding molecules known as "carbohydrate binding modules" (CBMs). CBMs suitable for use exhibit an affinity for sialic acid. Carbohydrate binding modules are classified into families and CBMs classed as members of the family 40 CBMs (CBM4Q) may be useful. The family 40 CBMs embrace molecules of approximately 200 residues and are often found at the N-terminus of GH33 siaiidases. They may also be found inserted in the β-propeller of GH33 siaiidases.

Exemplary carbohydrate binding modules for use may comprise the sialic acid binding domain of Vibrio choleras NanH sialidase (VcCBM: a CBM40) and/or the equivalent (or homologous) domain from Streptococcus pneumoniae NanA sialidase (SpCBM: also a C8M40). Of course similar or homologous sialic acid binding modules present in other organisms are to be encompassed within the scope of the term "CBiVT.

An exemplary Vibrio cholerae NanH sialidase amino acid sequence is deposited under accession umber A5F7A4 and is reproduced below as SEQ ID NO: 1 (781 amino acids).

The CBM region of SEQ ID NO: 1 is from amino acid residue 25 to 216 - this sequence may be SEQ ID NO: 2.

An exemplary Streptococcus pneumoniae NanA sialidase amino acid sequence has been deposited under accession number P62575 and is reproduced below as SEQ ID NO: 3 (1035 amino acids).

The CBM region of SEQ ID NO: 3 is from amino acid residue 121 to 305 - this sequence may be SEQ !D NO: 4,

Thus, CBMs for use as sialic acid binding molecules in the various aspects and embodiments of this disclosure may comprise a protein or peptide having the sequence of SEQ ID NO: 1 , 2, 3 or 4 or a sequence fragment derived therefrom and which encodes a molecule with an ability to bind sialic acid (in other words a sialic acid binding molecule encoding portion of fragment of SEQ ID NOS; 1 , 2, 3 or 4).

A useful sialic acid binding molecule may comprise a proteinaceous moiety encoded by the sialic acid binding domain of the nanH gene (encoding sialidase) of V. cholerae (as provided by SEQ ID NO: 1) or an equivalent or homologous gene present in another organism (for example the equivalent/homologous nanA sialidase gene of S. pneumoniae: see SEQ ID NO: 3).

A sialic acid binding molecule for use may comprise from about residue 1 , 5, 10, 15, 25 or 30 (i.e. from 1-30 or from any amino acid residue there between) to about residue 150, 175, 200, 210, 216, 220-781 (to any residue from 150 to 781 including any residue therebetween) of the V. cholerae sialidase molecule of SEQ ID NOS: 1 and 2. For example a sialic acid binding molecuie for use may comprise a peptide having a sequence corresponding to residue 25 to about residue 216 of SEQ ID NO: 1 above.

A further suitable sialic acid binding molecule may comprise a protein or peptide having the sequence of SEQ ID NO: 3 or 4 or a sialic acid binding fragment thereof. For example, a useful sialic acid binding molecule may comprise a proteinaceous moiety encoded by the sialic acid binding domain of the Streptococcus pneumoniae nanA gene (encoding sialidase). For example a sialic acid binding molecule for use may comprise from about residue 80, 90, 100, 1 10, 120, 121 to 130 (i.e. from any of about residues 80 to 130 including any residue therebetween) to about residue 250, 275, 300, 305, 310, 320-1035 (i.e. to any residue from about 250-1035 including to about any residue therebetween) of the S. pneumoniae sialidase molecule of SEQ ID NOS: 3 and 4. For example, a sialic acid binding molecule for use may comprise a peptide having a sequence corresponding to residue 121 to about residue 305 of SEQ ID NO: 3 above.

A sialic acid binding molecule for use may comprise one or more CBMs. For example, suitable sialic acid binding molecules may comprise single CBMs - for example a single VcCBM or a single SpCBM. Alternatively, a sialic acid binding molecule for use may comprise a plurality or multiple (i.e. two or more) CBMs. Siaiic acid binding molecules which comprise a plurality of CBMs may be termed "multivalent sialic acid binding molecules" or "multivalent CBMs". A multivaient CBM may, for example, comprise two or more (for example three, four, five or six) VeCBMs or two or more SpCBMs. A multivaient CBM may comprise a mixture of different CBMs, for example one or more VeCBMs with one or more SpCBMs.

Thus, the various aspects and embodiments of this disclosure (uses, sialic acid binding molecules for use, methods and medicaments) may exploit sialic acid binding molecules which comprise, consist of or consist essentially of siaiic acid binding molecules selected from the group consisting of:

(i) one or more VcCBM(s);

(ii) one or more SpCBM(s); and

(Hi) a multivalent CBM.

As such, the present disclosure provides Vc4CBM for use in the treatment and/or prevention of sepsis and/or one or more symptoms thereof.

Further provided is the use of Vc4CBM in the manufacture of a medicament for use in the treatment and/or prevention of sepsis and/or one or more symptoms thereof.

The disclosure also relates to a method of treating or preventing sepsis and/or one or more symptoms thereof, said method comprising the steps of administering to a subject in need thereof, a therapeutically effective amount of Vc4CBM.

For the avoidance of doubt, Vc4CBM comprises, consists essentially of or consists of four Vibrio cholerae NanH sialidase CBM units linked, bound or conjugated together. l/c4CBM may be described as a tandem-repeat multivalent protein based on the Family 40 sialic acid binding domain (CBM) of the nanH gene encoding the sialidase from V. cholerae, Molecules of this type may be generated using PCR-based cloning techniques and a suitable method for the generation of multivalent molecules of this type is described in, for example, Connaris et al, 2009 (Enhancing the Receptor Affinity of the Sialic Acid-Binding Domain of Vibrio cholerae Sialidase through multivalency; J. Biol. Chem; Vol. 284(1 1 ); pp 7339-7351). For example, multivalent CBM molecules, including the likes of Vc4CBM may be prepared as constructs comprising multiple CBMs linked by amino acid/peptide linkers. Each CBM (for example VcCBM) may be linked to another by, for example, peptides comprising 5, 10 or 15 amino acids. By way of example any one or more of the following peptides may be used to link two or more CBMs to produce a multivalent CBM:

(i) 5 amino acid linkers:

(ii) 10 amino acid linkers:

(ii.i) 15 amino acid linkers:

An exemplary Vc4CBM may take the following form:

This schematic shall be referred to hereinafter as General Formula 1.

Thus, a Vc4CBM molecule may conform to General Formula 1 as set out above, wherein Peptide Linkers A, B and/or C are selected from the linker options presented above as (i), (ii) and/or (iii). It should be noted that the term " VcCBM40" embraces not only the complete family 40 CBM derived from Vibrio cholerae (NanH sialidase) but also sialic acid binding fragments derived therefrom. Indeed, each of the VcCBM units shown in General Formula 1 may be selected from the group consisting of:

(i) a Vibrio cholerae NanH sialidase CBM; and

(ii) a Vibrio cholerae NanH sialidase CBM sialic acid binding fragment thereof.

Thus, each of the VcCBM units of the molecule shown in General Formula 1 may be the same or different.

The sialic acid binding molecules for use may further comprise an oiigomerisation domain. Suitable oiigomerisation domains may exhibit an ability to self-associate to form muitimer structures, for example trimers. An oiigomerisation domain for use may comprise any molecule with the above mentioned oiigomerisation properties or any functional fragment thereof. For example, one or more (for example two) sialic acid binding molecules (for example CBMs) may be bound, coupled or fused to an oiigomerisation domain - the resulting sialic acid binding molecule: .oiigomerisation domain "fusion" may then be used (with one or more other such "fusions") as a molecule for modulating cell growth and/or activity and/or for treating or preventing any of the diseases and/or conditions disclosed herein.

Suitable oiigomerisation domains may be derived from, for example, Pseudomonas aeruginosa pseudaminidase. An exemplary Pseudomonas aeruginosa pseudaminidase sequence amino acid sequence has been deposited under accession number PA0579 and is reproduced below as SEQ ID NO: 5 (438 amino acids).

The oiigomerisation domain of SEQ ID NO; 5 is from amino acid residue 333 to 438 - this sequence may be SEQ ID NO: 6.

Thus an oiigomerisation domain for use may comprise from about residue 250, 275, 300, 310, 320, 333, 340 to 350 (i.e. from about residue 250 to about residue 350 including from about any residue therebetween) to about residue 400, 410, 420, 430 or 438 (i.e. to about any residue from about residue 400 residue 438 including to about any residue therebetween) of the P. aeruginosa pseudaminidase trimerisation domain (PaTD) provided by SEQ ID NO: 5. For example, a useful sialic acid binding molecule may exploit an oiigomerisation domain comprising residues 333 to 438 of SEQ ID NO: 6.

A sialic acid binding molecule for use may comprise one or more of the CBM based molecules presented in Figure 1. For example, a suitable sialic acid binding molecule may comprise (consist essentially of, or consist of) two or more VeCBMs optionally fused, bound or conjugated to an oiigomerisation domain (such as a PaTD or oiigomerisation fragment thereof). The sialic acid binding molecule may comprise, consist or consist essentially of two fused (or bound) VeCBMs which are in turn fused to an oiigomerisation domain (see, for example, molecule Vc2CBMTD shown in Figure 1). Other sialic acid binding domains for use may comprise two or more SpCBMs optionally fused, bound or conjugated to an oligomerisation domain (such as a PaTD or an o!igomerisation fragment thereof). Sialic acid binding molecules for use may comprise, consist or consist essentially of two fused (or bound) SpCBMs which are in turn fused to an oligomerisation domain (see, for example, molecule Sp 2CBMTD shown in Figure 1).

Given thai sepsis is characterised by an exacerbated host immune response, the sialic acid binding molecuies of this disclosure (including, for example, Vc4CBfV1) may find application in compositions, medicaments and methods for moduiating sepsis associated immune responses, A sepsis associated immune response may be an immune response that, when compared to a normal immune response (e.g. one that is not a sepsis associated immune response) is exacerbated, exaggerated and/or inappropriate. As stated, the sepsis associate immune response may lead to host tissue damage and/or organ damage/failure and may comprise the dysregulation of innate immune responses as well as the production and/or over/under production of certain cytokines and/or pro-coagulation cytokines (including, for example, tumor necrosis factor, interleukin 1 and interleukin 6). Again, any dysregulation and/or cytokine over/under production may be measured, quantified and/or determined relative to the level of cytokine under/over-production and/or regulation in an uninfected host.

Thus, the disclosure provides a sialic acid binding molecule for use in modulating (for example dampening, inhibiting and/or ablating) a sepsis associated immune response. The disclosure may further relate to a method of modulating a sepsis associated immune response, said method comprising administering a subject in need thereof (the subject being a subject (i) suffering from sepsis and/or with a sepsis associated immune response or (ii) predisposed or susceptible thereto). The disclosure also provides the use of a sialic acid binding molecule in the manufacture of a medicament for modulating a sepsis associated immune response.

It should be noted that the various uses and methods described herein may comprise the administration of a non-cell cross-linking, non-cell or red/white cell agglutinating, non- blood clotting cascade/symptom and/or non-stroke/thrombosis symptom inducing or activating amount of a sialic acid binding molecule.

Sialic acid binding molecule based treatments, compositions, methods and medicaments (all of which are described herein - in particular those based on \/c4CBM) represent an advantage over prior art equivalents as the sialic acid binding molecules may not induce, cause or accelerate the release of microbial pro-inflammatory components which can exacerbate or induce sepsis and lead to severe sepsis and shock. Further, in contrast to antimicrobial peptides (AMPs), the sialic acid binding molecules are less toxic and less likely to be rendered useless through the development of resistance. Further, it should be noted that the various uses, methods and medicaments described herein may exploit one or more of the sialic acid binding molecules described herein. For example, two or more different sialic acid binding molecules may be administered to a subject together, concurrently or separately.

The present disclosure may provide compositions for use in the various uses, medicaments and methods described herein. As such, any of the sialic acid binding molecule(s) described herein may be formulated for use. For example, a sialic acid binding molecule (or molecules) may be formulated as therapeutic or pharmaceutical compositions. The various compositions may comprise one or more of the sialic acid binding molecules described herein and any given treatment may require the administration (together, concurrently or separately) of one or more of these compositions.

The various sialic acid binding molecules described herein may be formulated for enteral (including oral), parenteral and/or topical administration and one of skill will appreciate that the precise formulation may vary depending on the route of administration. Pharmaceutical compositions according to the present invention may be prepared conventionally, comprising substances that are customarily used in pharmaceuticals and as described In, for example, Remington's The Sciences and Practice of Pharmacy, 22nd Edition (Pharmaceutical Press 2012) and/or Handbook of Pharmaceutical Excipients, 7th edition (compiled by Rowe et al, Pharmaceutical Press, 2012} - the entire content of all of these documents and references being incorporated by reference.

A therapeutic or pharmaceutical composition of this disclosure (that is a composition comprising a sialic acid binding molecule and for use in any of the medicaments or methods described herein - including the methods of or medicaments for, treating or preventing sepsis) may be formulated together with one or more pharmaceutically acceptable excipients, carriers, adjuvants and buffers. The compositions can be administered, e.g. orally (including mucosaily), parentally, entera!ly, intramuscularly, subcutaneously, intravenously or via any other routes useful to achieve the desired effect (in this case effects which include, modulation of cell growth/activity, treatment or prevention of diseases/conditions associated with the same and/or cancer and/or modulation of tumour growth). As stated, depending on the chosen route of administration, the exact composition of the formulation may vary.

A therapeutic or pharmaceutical formulation comprising a sialic acid binding molecule and for administration to a subject may be coated, encapsulated or enveloped in a material which protects the sialic acid binding molecule from the action of enzymes, acids and other natural compounds/conditions (including, for example, compounds (including antibodies), cells and processes of the immune system) which may inactivate or denature the compound and/or its sialic acid binding properties. Among the various standard and conventional excipients that may be available for use in compositions comprising sialic acid binding molecules, are those pharmaceutically acceptable organic or inorganic carrier substances which are suitable for parenteral, enteral, oral (including mucosa!) and other routes of administration that do not deleteriousiy react with the sialic acid binding rnolecule(s).

Where the sialic acid binding molecules are to be formulated for parental administration, the compositions may be sterile.

The composition may comprise an oil-based or aqueous solution, a suspension and/or an emulsion.

in other embodiments, the composition may take the form of an implant, such as for example a (dissolvable or biodegradable) film, pessary or implant (including suppositories).

The pharmaceutical preparations comprising sialic acid binding molecules may be mixed with stabilizers, wetting agents, emulsifiers, salts (for use in influencing osmotic pressure), buffers and/or other substances that do not react deleteriousiy with the active compounds.

One or more of the sialic acid binding molecules described herein may be formulated for and administered, orally. As stated, oral administration would include mucosal administration which would itself would include administration intranasaSly and/or by inhalation.

Compositions for use may include solid dosage forms which are suitable for oral administration. These may include, for example, capsules, tablets, pills, powders, and granules. In any given solid dosage form, the sialic acid binding molecuie may be admixed with at least one inert pharmaceutically-acceptable excipient. Examples of suitable excipients will be known to one of skill in this field but may include, for example, fillers or extenders, humectants. wetting agents, binders, disintegrating agents, solution retarders, absorption accelerators, adsorbents, lubricants or mixtures thereof. A tablet, pill or capsule may further comprise a buffering agent. Solid dosage forms such as tablets, dragees, capsules, pills and/or granules also can be prepared with coatings and shells, such as coatings which protect against the gastrointestinal environment and/or stomach acid.

A solid dosage form may contain opacifying agents, and can also be formulated so as to ensure the delayed release of the active agent (in this case the sialic acid binding molecule) in or to a specific part of the intestinal tract.

Solid compositions for oral administration can be formulated in a unit dosage form, each dosage containing an appropriate dose of the sialic acid binding molecule. The exact amount of sialic acid binding molecule contained within any given solid dosage form will vary depending on the intended use. A solid composition may contain a "unit dose" - a unit dose containing a quantity of sialic acid binding molecule calculated to produce the desired effect (for example modulation of ceil growth and/or activity) over the course of a treatment period. Liquid dosage forms for oral administration may (as stated) include emulsions, solutions, suspensions, syrups, and elixirs. In addition to the compound or composition, the liquid dosage forms may contain inert diluents commonly used in the art, such as water or other solvents, solubilizing agents and emulsifiers.

Any suitable amount of a sialic acid binding molecule (for example any of the CBM type molecules described herein) may be used. For example, whether a composition comprising a sialic acid binding molecule (for example a CBM such as Vc4CBM or Vc2C8MTD) is to be administered intravenously or mucosaliy (for example intranasally) the dose of sialic acid binding molecule may comprise anywhere between about 1 pg and about 1000 pg. For example a dose of about (for example +/- 0.5 pg) 10 pg, 1 1 pg, 12 pg, 13 pg, 14 pg, 15 pg, 20 pg, 30 pg, 40 pg, 50 pg, 100 pg, 200 pg, 300 pg, 400 pg, 500 pg, 600 pg, 700 pg, 800 pg, 900 pg or 950 pg of the sialic acid binding molecule may be used. These amounts may be provided in any suitable volume of excipient, diluent or buffer. For example the amount of sialic acid binding molecule may be provided in anywhere between about 1 pi to about 5 ml of excipient, diluent or buffer. For example, the required amount of sialic acid binding molecule may be combined (or formulated) with about 5 pi, 10 pi, 15 pi, 20 pi, 25 pi, 30 pi, 35 pi, 40 p!, 45 pi, 50 pi, 55 pi, 60 pi, 65 pi, 70 pi, 75 pi, 80 pi, 85 pi, 90 pi, 95 pi, 100 pi, 200 pi, 300 p!, 400 pi, 500 pi, 600 pi, 700 pi, 800 pi, 900 pi, 1 ml, 2 ml, 3 mi or 4ml. For example, for intranasal administration and amount of sialic acid binding molecule (for example about 100 pg or 500 pg) may be formulated in about 50 pi excipient for use as a single dose. Further and for intravenous use, small amounts of sialic acid binding molecule may be used. For example amounts of about 10 pg, 1 1 pg or 12.5 pg, 13 pg, 14 pg or 15 pg may be used intraveneously.

DETAILED DESCRIPTION

The present invention will now be described in detail with reference to the following figures which show:

Figure 1 : Building blocks of the multivalent CBM forms and their affinities for sialic acid, a, VcCBM, residues 25-216 of the V. cholerae sialidase (PDB: 1w0p) with α -2,3~sialyllactose drawn as spheres, b, SpCBM, residues 121-305 of S. pneumoniae NanA sialidase with a- 2,3-sia!yl!actose (PDB:4c1w). c, TD, the trirnerisation domain, residues 333-438, of the P. aeruginosa pseudaminidase (PDB:2w38) in rainbow colours; the other two monomers in single colors, d, Multivalent forms: their molecular weights, valencies and binding affinities for a2,3-sialyl!actose as determined by surface plasmon resonance (SPR) at 25°C (K_D values for VcCBM, Vc2CBM and Vc3CBM had been reported previously⁷). Tandem repeat CBMs, and oligomeric CBMs fused to TD are linked by a 5-amino linker (details in Full Methods).

Figure 2: Survival time of mice infected intravenously only with 8.5X10° CFU/mouse (control) or with same number of pneumococci plus 12.5 pg/mouse Vc4CBM. The protein was administered with bacterial inoculums and mice were observed for 168 h. The survival time of each animal is shown with a dot. The median survival time is given with a horizontal line and was 59 h (SD: 53) for control and 84 h (SD:55) for Ve4CBiVl group..

Figure 3: Survival time of mice infected intravenously only with approximately 6.3-7.5X1 G⁶ CFU/mouse (control) or with same number of pneumococci plus 13-15 pg/mouse Vc4CBM. The protein was administered with bacterial inoculums and mice were observed for 168 h. The survival time of each animal is shown with a dot. The median survival time is given with a horizontal line and was 59 h (SD: 48.7) for control and 168 h (SD:48.5) for Vc4CBM- treated group.

Figure 4: The effect of intranasal administration of two mCBM40s on survival of Streptococcus pneumoniae D39-infected mice. CD1 outbred mice (n=20) were administered intranasally with either a single dose of 500 μg Vc4CBM (CBM1 ) or 100 μg Vc2CBMTD (CBM2) a day before (A), at the time of (B) or 1 day after intranasal infection (C) with S. pneumoniae D39. Control group received PBS only. Difference in percent median survival was calculated using Wilcoxon test. *p<0.05, ***p<0.001 relative to the control that received PBS.

Figure 5: The impact of mCBM40s on disease sign scores in pneumococcal infection. CD1 mice that received either 500 μ§ Vc4CBM (CBM1) or 100 ,ug VclCBUTD (CBM2) a day before (-1), at the time of (0) or 1 day after (+1 ) intranasal infection when administered with a lethal dose of S. pneumoniae D39, were monitored for signs of disease at 24, 36 and 48h post infection. A score of 2, 4, or 6 was given if the animals were piloerect, hunched, or lethargic, respectively. Each column represents the mean disease sign scores at different time points for 8 to 14 animals that eventually died. The vertical lines are for standard error of mean. Data was analysed by two-way AN OVA followed by Dunnett's multiple comparisons test. *p<0.05, ***p<0.001

Figure 6: The effect of mCBM40s on mortality time of Streptococcus pneumoniae infected mice after intranasal administration. CD1 mice were administered intranasally with either 500 Ltg Vc4CBM (CBM1 ) or 100 μg Vc2CBMTD (CBM2) a day before (-1), at the time of (0) or 1 day after intranasal infection (+1) with S. pneumoniae D39. Difference in time to mortality was calculated using Mann-Whitney U test. *p<0.05, ****p<0.0001 relative to the control that received PBS. Figure 7: The impact of CBiVl protein on pneumococcal bacteremia: CD1 mice received either 500 μq Vc4CBM (CBM1 ) or 100 ,ug Vc2CBMTD (CBM2) a day before (-1 ), at the time of (0) or 1 day after (+1) intranasal infection with lethal dose of S. pneumoniae D39. A blood sample was taken from the tail vein 24 h post infection and CFU/m! was determined by serial dilution and plating. Each column represents the mean CFU/mi for 8 to 14 animals. Vertical lines are for standard error of mean. Data was analysed by two-way AN OVA followed by Dunnett's multiple comparisons test. *p<0.05 relative

Example 1

When identifying different routes of mCBM40 delivery in vivo, it was noted that a tetrameric Vc-based CBM40 (Vc4CBM), protected mice when given intravenously with a iethai dose of Streptococcus pneumoniae. This suggests a role for CBMs (including multivalent molecules comprising the same) in the treatment and/or prevention of sepsis, its symptoms and/or associated pathologies.

Multivalent forms of CBM40s target sialylated cell surfaces and therefore it was expected that, at certain concentrations, agglutination of red (and white) blood cells in vivo would occur as a result of cross-linking protein-ligand interactions between cells. This could potentially lead to a number of blood clotting symptoms such as thrombosis or stroke.

The results of initial dose-response intravenous VcACBM dosing in mice and clinical activity show that an intravenous Vc4CBM dose of 12.5 pg/mouse was tolerated.

Production of the V'c4CBM in E. coli meant that it was necessary to eliminate contamination of the CBM preparation with endotoxin as the cause of any observed adverse events - this would ensure that the results represented a proper assessment of the effect the Vc4CBM molecule against sepsis. As stated an intravenous dose of 12.5 pg Vc4CBM was tolerated by mice and a pneumococcal challenge was attempted.

Groups of mice (n=5) were infected intravenously with a lethal dose of pneumococcus (8.5x10⁵ CFU/mouse) in the presence or absence of a single dose of Vc4CBM (12,5 pg/mouse). Survival times of mice are shown in Figure 2. There appeared to be a slight, increase in survival of mice in the CBM-treated group {median survival time ~ 84h) compared to the control group (59h). To determine whether the survival rate in mice could be improved, a further study was performed whereby the pneumococcal CFU dose was slightly reduced to correspond with a slight increase in the amount of Vc4CBM given intravenously. The results of this experiment are shown in Figure 3. Here it appears that the survival rate of mice improved significantly under the conditions tested, with a combined survival rate of 70% after 7 days in the CBM-treated groups, displaying a median survival time of 168h, compared to 20% survival of mice in the untreated, infected groups (median survival time of 59h). These resu!ts indicate that mCBM40s have the potential to alleviate symptoms of sepsis in a bacteriaily-infected host, in the case of VcACBM, it is likely that this biologic modulates the immune response by dampening down the pro-inflammatory cascade of a S. pneumoniae infection that leads to sepsis. Further, while there was a concern that the multivalent CBMs might (through the cross-linking of protein-!igand interactions between ceils) induce agglutination of cells (including red (and white) blood cells) in vivo (which could potentially lead to the induction of blood clotting cascades and a number of blood clotting symptoms such as thrombosis or stroke), this did not occur.

Example 2

Novel, bacterial!y-derived, proteins (mCBM40s) that target and bind host cell surface sialic acid-receptors with high affinity (JBC (2009), 284, 7339) have been engineered. When mCBM40s are administered in mice, they are shown to be non-toxic and can protect mice from respiratory pathogens (PNAS (2014) 1 1 1 , 6401 ; AAC 59(3): 1495-1504). Using a pneumococca!-challenged mouse model , it has been shown that rnCBM40, Vc4CBM can provide significant survival rates in mice against a lethal pneumococcal infection. To further evaluate the protective utility of mCBSV140 proteins in reducing bacteraemia in a pneumococcal mouse model, mCBM40s were also given intranasally (as described below). mCBM40 closing via the intranasal route

Method: Ail CBM40 proteins (l/c4CBM and Vc2CB!vlTD, endotoxin-free) were prepared as described in Connaris et al (2014)¹⁰. Groups of female mice (CD1 outbred strain, n= 10 to 20), weighing 28-35g, were intranasai!y administered with a single dose of either Vc4CBM (up to 500 μg) or VC2CBMTD (up to 100 μg ) in 50 μΙ sterile PBS, either one day before (D- 1 ), on the day (DO) or one day after (D+1) a lethal intranasal challenge with approximately 1X10⁶ CPU of S. pneumoniae D39 (in 50 μl of PBS)/mouse. The control group received PBS only. Clinical signs of disease were monitored and recorded over 7 days (168h), where an ascending score from 0 to 6 (0 being no clinical symptoms) was given to all animals. At the end of experiment, the lungs, and blood will be collected and bacterial counts determined. Bacteraemia was monitored by sampling blood at specific time-points during infection, with the number of colony forming units from blood determined using the technique as described by Miles and Misra^{1 1}.

Table 1. The impact of mCBM40 dosing on survival of CD1 mice challenged with a lethal pneumococcal dose. *Survival of treated groups was evaluated after 168 h.

Summary

1. mCBM40s demonstrated reduction of bacteraemia in mice when intranasally given in a lethal pneumococcal infection model.

REFERENCES

1."The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)". February 23, 2016. doi: 10.1001 /jama.2016.0287.

2. Jawad, I; Luksic, I; Rafnsson, SB (2012). Assessing available information on the burden of sepsis; Global estimates of incidence, prevalence and mortality. Journal of Global Health 2 (1): 010404.

3. Hoffman, SJ; Outterson, K; R0ttingen, JA; Cars, O; Clift, C; Rizvi, Z; Rotberg, F; Tomson, G; Zorzet, A (2015). An international legal framework to address antimicrobial resistance. Bulletin of the World Health Organization 93 (2): 66.

4. Bahar, AA; Ren, D (2013) Antimicrobial Peptides. Pharmaceutical (Base!) 6 (12): 1543- 1575.

5. Yeaman, MR; Yount, NY (2003) Mechanisms of antimicrobial peptide action and resistance. Pharmacol. Rev. 55:27-55

6. Fox, JL (2013). Antimicrobial peptides stage a comeback. Nature Biotechnology 31 : 379- 382

7. Connaris, H; Crocker, PR; Taylor, GL (2009). Enhancing the receptor affinity of the sialic acid-binding domain of Vibrio cholerae sialidase through muitivalency. J.Biol.Chem. 284(11 ): 7339-51

8. Connaris, H; Govorkova, EA; Ligertwood, Y; Dutia, BM; Yang, L; Tauber, S, Taylor, MA; Alias, N; Haga, R; Nash, AA; Webster RG; Taylor GL (2014), Prevention of influenza by targeting host-receptors using engineered proteins. PNAS 111 (17): 6401-6406.

9. Govorokova, EA; Baranovich, T; Marathe, BM; Yang, L; Taylor, MA; Webster, RG; Taylor, GL; Connaris, H (2015). Sialic acid-binding protein Sp2CBMTD protects mice against lethal challenge with emerging influenza A (H7N9) virus. AAC 59(3): 1495-1504.

10. Connaris H, Govorkova EA, Ligertwood Y, Dutia BM, Yang L, Tauber S, Taylor MA, Alias N, Hagan R, Nash AA, Webster RG, Taylor GL. 2014. Prevention of influenza by targeting host receptors using engineered proteins, Proc Natl Acad Sci USA 11 1 :6401-6406. 1 1. Miles, AA; Misra, SS; Irwin, JO (Nov 1938), "The estimation of the bactericidal power of the blood.". The Journal of Hygiene. 38 (6): 732-49.

Claims

1 . A sialic acid binding molecule for use in the treatment and/or prevention of sepsis and/or one or more symptoms thereof.

2. The sialic acid binding molecule of claim 1 , for use of ciaim 1. wherein the sialic acid binding molecule comprises one or more carbohydrate binding module(s).

3. The sialic acid binding molecule of claim 1 or 2, for use of ciaim 1 or 2, wherein the sialic acid binding molecule comprises one or more famiiy 40 carbohydrate binding module(s).

4. The sialic acid binding molecule of any preceding claim, for use of any preceding ciaim, wherein the sialic acid binding molecule comprises the sialic acid binding domain of Vibrio cholerae NanH sialidase and/or the sialic acid binding domain of Streptococcus pneumoniae NanA sialidase.

5. The sialic acid binding molecule of claim 4, for use of ciaim 4, wherein the Vibrio cholerae NanH sialidase comprises the amino acid sequence of SEQ ID NO: 1 or 2,

6. The sialic acid binding molecule of claim 4, for use of claim 4, wherein the Streptococcus pneumoniae NanA sialidase comprises the amino acid sequence of SEQ ID NO: 3 or 4.

7. The sialic acid binding molecule of any preceding claims, for use of any preceding claims, wherein the sialic acid binding molecule is Vc4CBM or Vc2CBMTD.

8. The sialic acid binding molecule of any preceding claim, for use of any preceding claim, wherein the sialic acid binding molecule is formulated for oral, mucosal or parenteral administration,

9. The sialic acid binding molecule of any preceding ciaim, for use of any preceding claim, wherein the sialic acid binding molecule is formulated intranasal administration.

10. The sialic acid binding molecule of any preceding claims, for use of any preceding claims, wherein the sialic acid binding molecule is formulated for intravenous administration.11. A sialic acid binding molecule for use in the treatment and/or prevention of sepsis and/or one or more symptoms thereof, wherein the sialic acid binding molecule comprises one or more sialic acid binding domain(s) of Vibrio cholerae NanH sialidase and/or one or more sialic acid binding domain(s) of Streptococcus pneumoniae NanA sialidase.

11. A method of treating and/or preventing sepsis and/or one or more symptoms thereof, in a subject in need thereof, said method comprising administering the subject a sialic acid binding molecule.13. The method of claim 12, wherein the subject in need thereof is a subject predisposed or susceptible to or at risk of developing sepsis, a subject with an infection which could lead to sepsis or a subject diagnosed as suffering from one or more sepsis associated pathologies and/or symptoms thereof.